Interim / Transition Care

Interim Care Services

Whether a patient is permanently home-bound or temporarily ​more money​ unable to leave their home to get care from a community physician, Trinity House Calls can take care of all of a patient’s long-term or short-term health care needs.

Seasonal Care

If you or a loved one suffer from a condition that worsens due to the heat of the summer months or at risk for falling during icy conditions in winter, Trinity  House Calls can take care of all primary care needs on a short-term basis during those seasonal months. So forget having to travel in uncomfortable seasonal conditions – we’ll bring top-notch medical care right to you.

Post-Discharge/Transition of Care

If you or a loved one were recently discharged from the hospital or nursing home, or are just having difficulty getting to a doctor’s office, we will work together with the primary care physician and all other necessary individuals to coordinate top quality care – even temporarily – until you or your loved one are ready to resume regular doctor visits.

Transition of Care (TOC) Program

Our Transition of Care (TOC) program is a 30-day post-discharge management program designed to help patients transition back into the community following hospitalization or nursing home admission. Patients are followed for 30 days – starting from the date of discharge – during the critical time period when they are most likely to develop complications that lead to avoidable re-admissions.

During the 30-day period, patients receive vital medical care through in-home provider visits and regular telephonic follow-ups. TOC will also coordinate a variety of services necessary to ensure patients recover quickly and remain safely in their homes.

Following completion of the 30-day TOC period, patients who have sufficiently recovered are redirected back to the care of the regular primary care providers.

The goal of TOC is to help recently-discharged patients avoid unnecessary hospital and emergency room re-admissions while ensuring quick healing and recovery right at home. Our TOC program includes the following high-quality, comprehensive services.